This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Thursday, April 07, 2011

The Danes consider going public with medical errors

And now a final report from the Copenhagen conference. By the way, it was entitled, "Fremtidens Hospitalsledelse", or "Future Hospital Management." I was asked to present our experience at BIDMC with regard to quality and safety improvement and transparency of clinical outcomes. Regular readers will have seen much of that history here.

Part of the story was our decision to widely publicize a wrong side surgery throughout our hospital in July of 2008. The result was a concentrated effort by dozens of people to evaluate what had gone wrong and to implement changes in our pre-op procedures.

I explained that the decision by our Chiefs to go public with the event took less than five minutes of discussion -- and that five years earlier, it would likely also have taken five minutes, but with the opposite result. The point was that a change in organizational culture takes time. There is an old expression, "Culture eats strategy for lunch." I think there is a lot to that, and I explained that the comfort our people felt with transparency was key to many improvements that led to an enhanced level of quality and safety.

Then, for fun, I used the polling electronics at the conference to ask the attendees whether they thought that their hospital would broadly publicize and disclose the kind of medical error that I had described. Here are the results:

This is quite different from the results at the Risky Business conference in London last year, where only a handful of 300 attendees gave a positive reply. Why the difference? Passage of time? An audience, here, that comprised more senior level people? A cultural difference between Britons and Danes? You can suggest your own theory.

7 comments:

Susannah
said...

Not to be overly cynical, but is there any chance 36% of the people said yes because you had asked the question and they knew it was the "right" answer in that context? On the other hand, if it was also you doing the asking at the Risky Business conference, as an apples-to-apples comparison that does make the growth in affirmative responses very interesting.

Paul, the important factor to me concerning your disclosure of BID's wrong site surgery error was the fact that it has been used as a case study by the IHI (and no doubt others) and fully dissected and analyzed by others. So it has become a learning exercise rather than some sort of mea culpa or confession.

I wish the AHA, who vigorously opposed CMS' disclosure of hospital-acquired infections(with more to come), and its member hospitals, would just get with reality. These errors are truly frightening in numbers as indicated by very recent publications. If the hospitals disclose them themselves, they not only accomplish the objectives you have described, but take control over how they are disclosed themselves, rather than whining over how the government does it. When are they going to grow up?

I had the same initial response as Susannah. Hypothetical questions rarely give us completely accurate responses. I believe that everyone who answered 'yes' would truly want to do the right thing, but put in the difficult situation, they might fall back to an easier, or at least more familiar, action. It does provide some comfort to know that more organizations are moving in the right direction, and as you noted, culture change does take time.

Paul, you should tell us if you are going to publish this data, because I just don't think it will pass peer review. On the other hand, if you were experimenting with methods of eliciting feedback about public reporting, you have stepped out in front of the herd to ask if others are doing something new.

There are huge structural and cultural defenses that reward a lack of public accountability. But there are other kinds of data that make reality transparent, including the stunning results in Health Affairs this month on the quantity of hospital harm, and multiple reports documenting physician lack of compliance in reporting errors, harm or colleagues when asked anonymously. Perhaps until we have universal public reporting, we should just report the physicians and hospitals who don't report.

And physicians and hospitals who are transparent should be rewarded by much higher ratings in social networking forums. Instead of the fluff of local magazines listing the top 100 doctors, perhaps it should be the top 100 doctors rated by aggressive participation in QI and public reporting. And transparent doctors and hospitals should say to their patients, "I'm sending you to x, because they have been engaged in quality improvement in medicine, not y, because who knows what they are up to." That is social marketing. That would be culture change.

I think anon is referring to publication in a peer-reviewed journal, with tongue in cheek. Goodness knows the peer review process has also taken a bashing lately. It appears that the trumpets are blowing and the walls of Jericho surrounding our cherished medical traditions are about to fall down. About time.